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III. Lethal Injection Procedures

You guys doing that right?
—Stanley “Tookie” Williams, at his December 14, 2005 execution, to a medical technician who, sweating and pale, spent eleven minutes probing Williams’s arm before she successfully established an intravenous line¹²⁹

The key to any claim that the standard three-drug lethal injection execution is not cruel is that the anesthesia renders the inmate unconscious and unable to feel pain before the other drugs are administered. Yet corrections officials do not ensure the anesthesia is effectively administered. During surgery, a trained anesthesiologist remains at the patient’s side to determine whether the patient has reached the proper level of unconsciousness before the surgery proceeds, and to ensure the patient remains unconscious for the duration of the procedure.¹³⁰ For reasons that remain unclear, however, state corrections agencies have not incorporated into their lethal injection executions the same safeguards that accompany the administration of anesthesia in medical procedures. State lethal injection protocols do not require execution teams to include persons trained in administering anesthesia, do not permit personnel to be close enough to the condemned inmate to monitor the administration of the anesthesia, and do not use trained personnel to determine whether the condemned inmate is properly anesthetized before the other two drugs are injected. 

The basic procedure states use in lethal injection executions is as follows:¹³¹ The condemned prisoner is brought to the execution chamber and strapped to a gurney. Some states allow the witnesses to watch the executioner(s) insert the catheter into the prisoner’s arm.¹³² Other states draw a curtain over the windows behind which the witnesses sit so they do not see the execution team insert the catheter into the condemned inmate.¹³³ The catheter is hooked up to an intravenous line that extends for at least several feet into the room where the execution team administers the injections. That room or space may or may not have a one-way mirror so that the executioners can look out at the prisoner without being seen. If the curtains were closed, they are opened. Witnesses see the prisoner alone in the chamber, already hooked up to the intravenous (IV) lines. The execution team, which consists of one or more people, will have prepared syringes with the drugs and syringes with saline solution used to flush the lines in between each drug. Upon a signal from the warden, the team begins injecting the syringes into the IV lines, one after another, in the prescribed sequence, without a break.

Some states use a more complicated procedure. For example, in Oklahoma, catheters are inserted into both arms.¹³⁴ Three executioners plunge eleven syringes in a complicated sequence, alternating the drugs between the left and right arms. It is not known who, if anyone, directs the sequence of drug administration for the executioners. The process is then repeated by injecting a second round of drugs. By the end of the process, the prisoner should have received two doses of sodium thiopental through the left arm, two doses of pancuronium bromide through the right arm, and two doses of potassium chloride (one dose through each arm).

Oklahoma’s current method of administering the lethal drugs differs from that originally developed by Chapman. The protocol Chapman developed called for a continuous infusion of sodium thiopental and did not split the drugs between the two arms. His protocol also called for observation of the IV site. These protections no longer exist in the current Oklahoma protocol. It is not clear whether Oklahoma ever executed its inmates using Chapman’s protocol, or when and why the changes where made.¹³⁵ When Human Rights Watch asked Chapman if he had concerns about the ways states today were administering lethal injection executions, he noted, “The question [of the drugs] being administered properly, that never came up in my mind. I never knew we would have complete idiots injecting these drugs. Which we seem to have.”¹³⁶

Missouri is the only state known to use a femoral venous IV, in which the IV is inserted into the femoral vein in the groin area.¹³⁷ A small needle is used to inject a local anesthetic. A larger needle is inserted into the femoral vein, and, once blood is obtained, a wire is threaded through the needle into the vein, and the needle is withdrawn. Then the IV catheter is threaded over the wire and into the vein. The catheter is then secured by suture. Little is publicly known about the training and expertise of the execution personnel who perform Missouri’s complicated femoral IV access executions. While the limited public record indicates that a surgeon creates the IV access, it is unclear what their role is in the conduct of the execution.¹³⁸ The attempts by condemned prisoners to discover the information through litigation have been rebuffed by the state’s refusal to answer questions posed in the plaintiff’s depositions and interrogatories.¹³⁹

Qualifications of Execution Team

Most lethal injection protocols say little or nothing at all about the training, credentials, or experience required of persons who will be on the execution team, either the person who inserts the catheter or the persons responsible for injecting and monitoring the drugs. No state lethal injection protocol expressly requires the team to include an anesthesiologist or someone with training in anesthesiology.

Twelve state lethal injection protocols contain no reference at all to the qualifications of the executioners.¹⁴⁰ Eight protocols refer generally to “training,” “competency,” “preparation,” or “practice,” but they do not elaborate further.¹⁴¹ For example, North Carolina’s protocol states: “Appropriately trained personnel enter behind the curtain.” But it does not explain what would constitute appropriate training.¹⁴² According to Texas’s protocol, “a medically trained individual (not to be identified) shall insert an intravenous catheter into the condemned inmate’s arms.”¹⁴³ The frequent problems Texas executioners have had with the insertion of catheters certainly raises questions about the actual training of the individuals who insert the catheter. (See Chapter Six on “Botched Executions” for descriptions of such problems.) Texas’s protocol does not refer to the qualifications of any other participants in the execution. California’s protocol states: “The angiocath shall be inserted into a usable vein by a person qualified, trained, or otherwise authorized by law to initiate such a procedure.”¹⁴⁴ Again, like Texas, there is no reference to qualifications of other members of the execution team. Similarly, Florida’s protocol does not refer to the qualifications of the execution team members. Florida does require the presence of a doctor and a physician’s assistant in the room, but their role in the execution is not clear.¹⁴⁵ What is known is that Florida pays its executioner, described only as a “private citizen,” $150 for each execution. Florida recruits its executioners by advertising in local newspapers.¹⁴⁶

Even though not expressly included in their protocols, a number of states have disclosed the qualifications of at least some of their execution personnel. In Pennsylvania, Colorado, and Georgia, for example, the corrections departments use trained Emergency Medical Technicians (EMTs) to insert the catheter.¹⁴⁷ Ohio uses an EMT and a phlebotomist to start the IVs, and an EMT administers the medication.¹⁴⁸ Tennessee uses two paramedics to insert the IVs.¹⁴⁹ Oklahoma uses a phlebotomist to insert the IVs.¹⁵⁰

Emergency Medical Technicians may be trained to insert catheters, but they are not ordinarily trained in the intravenous administration of anesthesia. Indeed, they may not even have a basic knowledge of the nature of the drugs they will administer. For example, Louisiana EMTs who administer the drugs during lethal injection executions have revealed they knew nothing about the drugs used in the procedure, including the anesthetic.¹⁵¹ The warden of Louisiana’s State Penitentiary, who is responsible for ensuring that the EMTs involved in Louisiana’s execution are qualified to perform lethal injection executions, recently stated that he has “no clue” as to whether the EMTs on his lethal injection execution team have been trained in intravenous administration of anesthesia.¹⁵² North Carolina’s Secretary of the Department of Corrections has acknowledged that he is ultimately responsible for his state’s lethal injection executions.¹⁵³ Yet when asked about the medical qualifications of the execution team, he stated: “I don’t know what—I would assume a nurse at least or someone else who is certified to insert a needle.”¹⁵⁴

The absence of appropriate medical training extends to something as basic as strapping the prisoner correctly. If the straps used to secure an inmate to the gurney are improperly secured, they can stop the delivery of the drug from the intravenous site in the prisoner’s arm to the prisoner’s brain.¹⁵⁵ A member of Louisiana’s execution strap-down team acknowledged he had never received any training from medical personnel about how to fasten the straps without restricting the prisoner’s circulation.¹⁵⁶ One of the botched executions in Chapter Six, below, exemplifies the problem of too-tight straps.

Checking the IV Equipment

Because problems in drug delivery systems and equipment malfunction can lead to the ineffective administration of anesthesia, the American Society of Anesthesiologists (ASA) emphasizes the importance of having medical personnel check the functioning of the anesthesia delivery system every time it is going to be used.¹⁵⁷ The ASA stresses the importance of having a checklist protocol for the anesthesia machines and equipment, to assure that the desired doses of anesthetic drugs will be delivered.¹⁵⁸ We do not know how many states check their intravenous equipment before using it for executions, nor do we know the qualifications of the persons who do the checking. A warden in North Carolina admitted that, while his execution teams do have a checklist protocol, it is “not used or practiced. I don’t know the last time [it] was actually used.”¹⁵⁹

The nature of the set up in execution chambers also increases the possibility of problems with the equipment. All the lethal injection drugs are administered from behind a screen or wall several yards away from the prisoner. The length of the intravenous tubing itself is thus problematic, because it requires multiple IV extension sets and connectors, increasing the risk of kinks and leaks.¹⁶⁰

The ASA (in its Practice Advisory) underscores the importance of having an anesthesiologist near the patient to in order to verify that the intravenous access equipment, including its infusion pumps and connections, are properly functioning and to visually monitor the flow of the anesthesia into the veins.¹⁶¹ In lethal injection executions, however, such monitoring is not possible because of the distance of the execution team from the equipment. For example, because of the distance, the executioners cannot immediately determine if the anesthesia is leaking into the surrounding muscle tissue because of an improperly inserted or secured needle.¹⁶²

Level of Anesthesia Not Monitored

Finally, and most crucially, corrections agencies do not permit anyone to monitor the prisoner’s level of anesthesia before the second and third drugs are administered. Standard medical—and even veterinary—practice requires a hands-on determination of the depth of anesthesia of the patient, or of an animal, before the initiation of any painful procedures.¹⁶³ Yet during lethal injection executions there is no one, much less someone trained in anesthesia, who either ascertains a prisoner’s sedation level before the next two painful drugs are administered, or who continuously monitors the inmate’s consciousness levels throughout the execution until the prisoner has died. Similarly, there is no one who can make necessary adjustments to dosage amounts, should a problem emerge.¹⁶⁴

Many condemned prisoners fall within a category of persons the American Society of Anesthesiologists has deemed most at risk of experiencing intraoperative awareness because of a history of past intravenous drug use, obesity, and other factors of poor health.¹⁶⁵ When a paralytic agent such as pancuronium bromide is used in surgery on such persons, it is especially important that anesthesiologists carefully monitor the delivery and the patient’s reaction to the anesthesia to ensure the patient is unconscious.¹⁶⁶

The patient’s depth of anesthesia during surgery is typically assessed by a number of factors, including but not limited to the patient’s motor functions, responses to noxious stimuli, and reflexive responses.¹⁶⁷ The ASA warns that when a neuromuscular blocking agent is used in combination with anesthesia, it will mask a patient’s response to stimuli, making it harder for a trained anesthesiologist to determine whether he is appropriately anesthetized or just paralyzed and unable to signal consciousness.¹⁶⁸ In such situations, the anesthesiologist monitors anesthetic depth through “a continuous real-time assessment of an array of physical signs and monitor signals, which may include the patient’s heart rate, systolic blood pressure, diastolic blood pressure, EKG waveform, EEG waveform, pupil size, and anesthetic gas concentrations, which then must all be related to the intensity of the ongoing surgical stimulation. Such monitoring is part science and part art, and it takes a considerable amount of hands-on training and experience.”¹⁶⁹ Despite the critical importance of this monitoring to ensuring a pain free execution, Human Rights Watch is not aware of any state that requires it.

In North Carolina, the warden in charge of overseeing lethal injection executions did not doubt that prisoners were sufficiently anesthetized when the other drugs were administered. During a deposition, the warden said he could tell the prisoners were anesthetized because: “At the time we administer Pavulon, the inmate is snoring deeply. It is obvious that he’s asleep and unaware . . . In 24 executions, I have never seen one that did not snore.”¹⁷⁰ The deposition continued:

Q: And the snoring is the key for you?

A: Yes.

Q: Is there anything else done to determine the level of unconsciousness at the time the Pavulon is administered other than to note the snoring?

A: Is there anything else done?

Q: Is there any other procedure used or anything else done to determine the level of consciousness at the time the Pavulon is administered?

A. No.¹⁷¹

The Secretary of the Pennsylvania Department of Corrections told Human Rights Watch that during lethal injection executions, the condemned inmate’s head is near the window through which the executioners can see him. This way, the executioners can see that the inmate looks asleep when they administer the other two drugs following the anesthesia.¹⁷² Yet according to Dr. Peter Sebel, an expert on measuring anesthetic depth in patients during surgery, “snoring” or “whether the patient appears to be asleep” are “not adequate measures of anesthetic depth.”¹⁷³

Corrections officials have not publicly explained why no one with appropriate training remains alongside the prisoner to determine the effectiveness of the anesthesia before the other drugs are administered. Maybe they want to protect the anonymity of members of the execution team. But their identities can be hidden from the public through surgical caps and masks, standard issue uniforms and shoes. Maybe they want to spare someone who is participating in an execution from having to stand in intimate proximity to the person being killed. Human Rights Watch recognizes that standing alongside a person being killed would—indeed should—be emotionally difficult. But corrections agencies should not put prisoners at risk of pain simply to spare the feelings of the executioners.